sCieNCe oF MediCiNe | Feature series
The Diagnosis of Decompression Sickness
in Sport Divers
by John P. Kirby, MD
Abstract
Hyperbaric oxygen therapy
(HBO2) remains the primary
treatment for decompression
sickness (DCS)—which can be
Treating sport diving obviously serious or infrequently
patients may be outside more minor and can get missed
of a clinician’s usual outside of centers that routinely
comfort zone, but there handling diving medicine. This
are resources through review will point out the salient
professional societies to
items for how sport or amateur
assist both patients and divers might present for HBO2.
clinicians to seek and
receive hyperbaric oxygen
Overview
treatments.
Currently, HBO2 is so commonly
used for wound healing applications
that outside of hyperbaric centers
near water that often treat DCS,
lower grade or sport diving cases of
DCS can get missed. Even though
treatment with HBO2 for DCS is one
of the most accepted indications and
historically has some of the strongest
data supporting its use.1 Cases of
DCS can be obvious due to their
preceding diving history and classic,
immediate symptoms of joint pain
and neurologic deficits, but they can
also present with atypical symptoms.2
There are between 2.7 and 3.5
million scuba divers in the U.S. and
more than 6 million worldwide.3
Clinicians should appreciate that
with the popularity of sport diving
there is considerable variations in
John P. Kirby Md, FaCs, is the director of training, experience, supervision,
Wound Healing Programs, associate Professor
of Surgery, Section of Acute and Critical Care and equipment being used. Often
surgery, at Washington university school of sport dives are organized along
Medicine, Barnes-Jewish Hospital, in St. Louis,
Missouri.
several amateur and professional
Contact: kirbyj@wustl.edu society guidelines, and the first
Missouri Medicine | May/June 2019 | 116:3 | 195
sometimes misleading nugget of
information is that a diver ascends
having no violation of the safe,
planned dive sequence and that
other divers with them have no
symptoms. It should be noted
that DCS, including more minor
variants, can be highly variable
based upon the individuals state of
health and hydration, as well as how
other dive factors beyond the depth
and bottom time. Temperature of
the water and any physical exertion
during the dive may also play a
role for the individual.4 So the
presenting patient doesn’t think
DCS is really an etiology for their
complaints and leads with no
violation of the dive protocol and
no one else being symptomatic.
DCS can also occur in relatively
shallow depths—in fact there have
been isolated cases in children
in ver y shallow, 1 meter depths.5
Usually depths of about 20 feet are
more common for DCS.6 Children
may not intrinsically accommodate
with exhaling on ascent and may
have more asymptomatic cardiac
defects, such as a persistently
patent foramen ovale. Anecdotal
stories exist of children watching
a pool cleaner go about cleaning
the bottom of a home’s pool using
some kind of air deliver y circuit
and joining that worker where they
also breath air at depth and then
pop to the surface. This is given
as an example where DCS might
sCieNCe oF MediCiNe | Feature series
Figure 1. Flow diagram showing the interrelationships between different classifications of diving-related illness.
Source: MedEdPORTAL
be missed if that same child presents with nonspecific
malaise and joint pain several days later. Figure 1.
Atypical Presentations Can Present
Lower severity DCS cases often have nonspecific
symptoms of pain near major joints, musculoskeletal
aches and malaise, numbness and paresthesia and
sometimes skin complaints like itching or rashes.
Major or Type II DCS have more severe musculoskeletal
pain or neurological symptoms (including those related
to the inner ear and balance problems, vertigo tinnitus
or nausea) or cardiopulmonar y complaints.7 Lower
severity DCS can be missed as so atypical and can
present to a primar y care physician that doesn’t often
care for diving problems.
Although Missouri is essentially landlocked, diving
accidents can and still occur in lakes, rivers, and even in
rarified, complex arrangements, like diving in a body of
water contained at depth inside of a cave. However, a
more common presentation in land locked areas are from
sport diving vacations.
Clinicians who themselves are not sport SCUBA
divers may not be familiar with diving vacations. Typically
a dive vacation is arranged for sport SCUBA divers to
fly on a commercial plane to a scenic, warm place to
dive as the focus of the vacation package. It is usually
recommended and most diving vacations or the dive boat
have some affiliation with one of the recognized diving
196 | 116:3 | May/June 2019 | Missouri Medicine
associations. In a typical dive vacation over three to
five days, the vacationers go to their deepest depths
early if not in the first dive. The usual history is that
there were no recognized breaks in the dive plan, no
appreciated problems with the bottom time or ascent
and someone comes up to the surface and begins
having vague, but persistent symptoms like joint pain
in the shoulder hips or legs. Typically the presentation
is not a classic debilitating one that everyone can
immediately appreciate as DCS, but often is bad
enough that the patient themselves do not go back for
any subsequent descents and/or the dive master refers
them back to the resort doctor. It is often the case
that neither the patient (who has shelled out for the
vacation) nor any of the vacation staff is enthusiastic
about labelling it as DCS, and to be fair often the
symptoms are often mixed. Often there are tips-offs
that can assist in the diagnosis.
Sport Diving DCS Diagnosis Tip Offs
The first is sometimes that patient might insist
upon going ahead with the next dive, and when they do
they feel better even at a lower depths (recall the first
dive is often the deepest) and then feel worse again
when they come up. They may notice that they kind
of feel better just at the depth of the resort pool as the
bench themselves from further real SCUBA diving.
During this period they should be concentrating
on hydrating themselves well, controlling pain with

NSAIDs, and avoiding alcohol due to its diuretic
effects—although alcohol is often consumed in self-
treatment. Even before HBO2 , just 100% oxygen can
be offered. So the typically low grade DCS sport diver
toughs it out for the next several days, feels a little better
each day, and then second red flag is the flight home.
Many commercial airline flights may not completely
pressurize to sea level as just approximating sea level
saves weight and fuel.8 So if a patient, our sport diver,
boards the plan with mild resolving DCS, it gets worse
at altitude and then when the plan lands it again gets
better. An all too common sequence of events is that the
sport diver leaves the work week early for a long weekend
diving vacation. They arrive at the resort at the beginning
of the weekend and are in the water shortly thereafter.
When they come up from that first, deepest dive, even
though nothing went wrong, they have symptoms. They
are reassured that it isn’t likely to be DCS, but to be
on the safe side they are recommended not to continue
on with the sequence of dives. They tough it out, and
just about the time that they fly home at the end of the
weekend, they are getting better. Then they worsen
on the flight home and again improve when they land.
However, often they are now calling their primary care
physician Monday morning, who then reaches out to a
local HBO2 center. Sometimes the call doesn’t come
until later in the week or even the following week.
Calls like this should prompt an evaluation looking
for the DCS exposure mechanism and the symptoms in
the patient. Most of these patients are themselves very
active, healthy, and unless they have had some change in
their overall health status, like an opening of a shunt or
a popping of a pulmonary bleb have little to no safety
contraindications to HBO2 treatment. All patients
should undergo good safety screening for HBO2. It is
recommended that physicians who do not commonly
treat patients with DCS contact one of the national
societies like Divers Alert Network (DAN) to improve
their evaluation exam to minimize omissions (such as
more serious complications and not overlook pre-existing
conditions like a patent foramen ovale) as well as to plan
for treatment options. DAN maintains a 24-hour call
center and potentially available facilities, should such a
DCS even occur at 1-919-684-9111. Although major
cases of DCS might need increased pressures or longer
treatment times, often sport divers with less severe
symptoms might do just as well with a timely offering of
sCieNCe oF MediCiNe | Feature series
HBO2 at depths commonly available in even outpatient
settings between 2.8 and 3 atmosphere absolute (ATA).
HBO2 treatment for DCS is one of the shorter
sequences of no more than 10 treatments before
utilization review. Often sport divers may need only a
few treatments for a full recovery. Officially there is no
time delay where HBO2 is withheld where it is too late,
but the longer the symptoms persist without treatment
the more likely that any treatment will be as successful.
It should also be appreciated that the diagnosis of DCS
may remain in doubt in a healthy patient without any
safety concerns for a trial of HBO2 and it is the patient’s
early improvement on the very first hyperbaric treatment
that is confirmatory for all.
Conclusions
In conclusion, severe cases of DCS, decompression
illness, and arterial gas embolism may be relatively
obvious due to their antecedent mechanism of exposure
to pressures or gases or instrumentations. Lower grade
DCS may present with atypical symptoms in sport divers
to general clinicians who should include this in their
differential even if no violations of any diving protocol
occurred. Nearly all of these patients may be able to
be treated in existing facilities as few require more than
3 ATA and often they may even qualify for outpatient
treatments. Although treating such sport diving patients
may be outside of a clinician’s usual comfort zone, there
are many helpful resources through professional societies
to assist both patients and clinicians to seek and receive
hyperbaric oxygen treatments.
References
1. Richard Moon, Chapter 7 Decompression Sickness in UHMS Hyperbaric
Oxygen Therapy Indications 13th Edition Lindell K Weaver Editor 2014 Best
Publishing North Palm Beach Fla
2. www.diversalertnetwork.org/.../Signs-and-symptoms-of-DCS
3. www.dema.org
4. Van Liew HD, Flynn ET. Direct ascent from air and N2)2 saturation dives in
humans DCS risk and evidence of threshold UHMed 2005; 32: 409-419.
5. Benton PJ, Woodfine JD, Westwook PR Arterial gas embolism following a 1-
meter ascent during helicopter escape training a case report . Aviat Space Environ
Med. 1996; 67: 63-64.
6. Francis TJR, Mitchell SJ Manifestations of decompression disorders. In:
Brubakk AO, Neuman TS editors Bennett & Elliots’s Physiology and Medicine of
Diving. 5th ed. New Yrk, NY: Elsevier Science; 2003. P. 578-599.
7. Vann RD, Butler FK, Mitchell SJ, Moon RE. Decompression Illness. Lancet
2011; 377: 153-164`1
8. www.diversalertnetwork.org/flyingafterdiving
Disclosure
None reported. MM
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